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What can we learn from Indian healthcare?

Ami Banerjee
Last edited 30th July 2010

Over the last few days, the Prime Minister has led a large, high-powered delegation to India promoting greater collaboration between the UK and India in areas as diverse as health and science to trade and climate change and education. Vince Cable, the Business Secretary, was very impressed by what he saw in the Narayana Health City (one of the largest medical facilities in the world) in Bangalore (one of the top four technological hubs in the world). The Narayana Hospitals (between Bangalore and Kolkata) currently have 5000 beds in India and aim to have 30,000 beds in the next 5 years in India. In terms of cardiac care they are doing some amazing work there against the odds: treating patients from 73 countries with complex heart disease and doing the largest number of heart surgeries on children in the world. No wonder Vince Cable was impressed.

In countries such as India, patients can have a massive array of procedures from cataract surgery to coronary artery bypass graft surgery at a fraction of the cost in the Western world. The massive growth of the private health sector in India has increased efficiency and quality. In the UK, medical tourism has been authorised for certain procedures as a way of reducing costs and waiting lists, and increasing consumer choice. This trend is set to increase after the European Court of Justice established the right of European citizens to seek treatment abroad if they are entitled to it in their own country but have suffered an unreasonable delay. There are now a massive number of medical tourism companies which will organise all aspects of healthcare abroad and a relaxing holiday afterwards. The Confederation of Indian Industry estimated that 150,000 medical tourists came to India in 2005, and the health care market, which includes health insurance, is set to expand by 2012 from US$22.2 billion (5.2% of GDP) to US$69 billion (8.5% of GDP).

There is another side to this coin. India has probably the worst health and wealth inequalities of any country in the world. The new “multidimensional poverty index” designed by the Oxford Poverty and Human Development Initiative showed that Bihar, the poorest state in India, has more poor people (95 million) living there than do nine of ten poorest countries in Africa. In 2001, India had only 35 well-equipped centres for modern diagnosis and treatment, mostly located in the six metropolitan cities; this is grossly inadequate for a vast country with an immense population such as India. The Narayana Hospitals currently do 12% of all cardiac surgery in India. That probably tells us that across the population there is not that much heart surgery going on.

The problem of inadequate resources is compounded by the fact that despite being one of the world’s major sources of medical staffing, the number of physicians per 100,000 population is less than 50. To plug the “brain drain”, the Indian government is starting a shortened, rural medical training programme to train and retain doctors in the poorest areas of the country. This is an innovative scheme which other developing countries will be watching closely.

So what can we learn from Indian healthcare? Firstly, sophisticated, world-class healthcare can be performed at a fraction of the cost of healthcare in the US and the UK with equal if not superior quality in the private sector of developing countries. Secondly, private healthcare does not at all reflect the health of the nation and often broadens health inequalities. On this point, the Narayana Hospitals are truly remarkable as they incorporate many societal initiatives such as microfinance and education. Thirdly, as flows of patients, doctors, and resources across country borders are all likely to increase in the future, improvements in the planning of our own healthcare resources and the way we interact with other countries (such as India) are a necessity.

Evidence 2010

Carl Heneghan
Last edited 15th June 2010

Right now, you would have to have been asleep to not realize implementing cost-effective change based on evidence is the key challenge for health systems around the world. beciause this its the most pressing problem we decided to bring together a conference of the evidence creators and evidence users to define the processes for implementing best clinical practice and forging efficient and cost-effective solutions for healthcare.

We would like you to join us at Evidence 2010, the leading evidence-based healthcare event at the forefront of EBM debate and innovation.

The conference is a collaboration between the BMJ and the Centre for Evidence Based Medicine CEBM.

The aims of the conference are to:

* Improve evidence-based decision making and provide practical, evidence-based ideas that can be implemented in practice
* Foster effective innovation
* Guide efficient commissioning
* Provide education and training to improve evidence-based healthcare.

We've got some great speakers lined up including:
Jim Easton, Sir Iain Chalmers, Sir Muir Gray Victor Montori,
Paul Glasziou, Mike Clarke, Sharon Straus,
Giordano Perez Gaxiola, Steven Woloshin, Fiona Godlee, Bill Summerskill, Helen Lester, Rubin Minhas, Amanda Burls, Dan Lasserson, Dyfrig Hughes, Tony Rudd, Tim Ringrose, Tom Jefferson, Ann McPherson, and Fiona Fox
Oh and not to mention Ben Goldacre Bad Science.Net

Look forward to seeing you there, Carl

A Health Select Committee report on the use of Management Consultants in the NHS and Department of Health estimated that the NHS spends upto £600 million per year on consultancy services, representing one fifth of total annual public sector consultancy spending, and the amount has increased in recent years. All areas of the health service: Strategic Health Authorities, Primary Care Trusts and NHS Trusts seem to like spending their money on external consultants, who often charge in excess of £1,000. Based on the committee’s recommendations, the government’s response last year was to call for centralized and local collection of data about what is being spent on management consultancy in the different sectors of the health service.

Last night, I was at the Royal Society of Medicine in London for a Salon, hosted by Diagnosis. Set up by junior doctors, Emma Stanton and Claire Lemer a few months ago, Diagnosis is a "healthcare consultancy for organisations such as the NHS, Department of Health and arms length bodies such as the Health Foundation”.

Management consulting can be traced back to a firm, Arthur D Little, set up by an MIT professor of the same name in 1886. Particularly after the Second World War, there was a huge demand for consultants who could offer a new perspective and strategic expertise within organisations. If you speak to management consultants, and I spoke to a few at last night’s networking event, they all mention “quality” and “performance improvement” as the key skills which they bring to an organisation. Interestingly, the same words appear repeatedly throughout Lord Darzi’s NHS Next Stage Review. Perhaps he wants doctors to be more management consultants and less medical consultants.

The fundamental tenet of Diagnosis is that there is a vast untapped resource among health professionals which can be as useful as any existing management consultancy, and importantly has a clinical perspective which the large consultancies such as McKinsey are lacking. "Diagnosis invites high potential junior doctors, medical students and allied health professionals into a virtual talent pool as Associates. Individuals are contracted at a daily rate to contribute towards a portfolio of projects that can be carried out alongside clinical and other professional commitments." Traditionally, doctors have felt that management and performance improvement roles are the remit of other people within the healthcare arena, and so have missed out on a great opportunity to influence and change healthcare, but also to use their expertise and experience in an unconventional way. One recent project involves producing an innovative 'Induction to the NHS' DVD for 7,000 newly qualified junior doctors. Stanton and Lemer are both passionate about the role of doctors as future healthcare leaders to change the culture of the NHS and you cannot help but be inspired by the massive combined potential that must be lurking throughout the organisation.

Another word that was bandied about a lot was “trust”. The trust that a client should have in their friendly management consultant. The trust that a patient should have in their doctor. In the 2002 Radio 4 Reith Lectures, Onora O’Neill, Cambridge philosopher, spoke of the “crisis of trust” in public organisations. There is surprisingly little consensus on what trust means in the healthcare setting and little evidence that any particular intervention can change a patient’s trust in their doctor. However, doctors do have a unique position of trust with patients and society which may also put them in a unique position to change healthcare practices.

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